Aims and Objectives: To study loneliness, depression and coping mechanism and the relationship between these factors in depressed and non-depressed elderly.Materials and Methods: Cross sectional study was done on 46 depressed and 48 non-depressed elderly were assessed clinically and using Geriatric Depression Scale-Short form [GDS-SF], loneliness scale, and brief cope scale. Statistical analysis was done using SPSS 20 software.Result: Mean GDS scores, mean loneliness (emotional and social) scores of depressed patients were higher than that of non- depressed, and this difference was found to be statistically significant [GDS: t = 14.33, p<0.001, loneliness Score: t = 7.23, p<0.001]. Self-distraction (mal-adaptive-passive) was the most commonly used coping mechanism in depressed group, while in the non-depressed group active coping (adaptive) was most common coping mechanism. Loneliness (emotional as well as social subscale) was a significant predictor of depression in both depressed and non-depressed group (Beta = .714, p<0.001) and (Beta = .629, p<0.001) and predicted 51% and 39% variance in depression respectively. Loneliness appeared as a distinct factor which seems to have a temporal and synergistic relationship with depression. Use of more adaptive coping mechanisms is associated with decrease in loneliness and depression while use of maladaptive coping mechanism is associated with decreased depression and loneliness in elderly.Conclusion: Loneliness is an important distinct factor in predicting depression in elderly. Coping mechanisms used, also affects loneliness and depression significantly.

These words describe the feeling of most of the elderly in our country. The phenomenon of population aging is becoming a major concern for the policy makers all over the world. The elderly population (aged 60 years or above) in India account for 7.4% of total population in 2001. For males it was at 7.1%, while for females it was 7.8%. Both the share and size of elderly population is increasing over time. From 5.6% in 1961, it is projected to rise to 12.4% of population by the year 2026. [1] The demographic change is probably due to the decreasing fertility and mortality rates due to the availability of better health care services. [2] Despite the life expectancy and the facilities that medical and social systems provide to elderly, they experience problems like loneliness; depression etc. [3] Population aging also generates variety of social and health problems, among which of special concerns are the problems related to psychological well-being of elderly. [4]

Loneliness is not a new concept in research. Loneliness is not synonymous with being alone, nor does being with others guarantee protection from feelings of loneliness. [5] Loneliness has been described as a complex set of feelings that occurs when intimate and social needs are not adequately met and that drives individuals to seek the fulfilment of these needs. [6] It is a universal phenomenon found in the humans and is closely associated with changing life circumstances. Old age is often seen to be marked by loneliness. Studies have shown that loneliness is linked to depression, lower quality of life and increased vulnerability to both physical and mental health problems of the elderly. These associations have been shown to be independent of age, education, income, marital status, and perceived stress. [7]

It has become common to distinguish emotional and social loneliness. Emotional loneliness is missing an intimate attachment, such as a marital partner, and is accompanied by feelings of isolation and insecurity, and of not having someone close, while social loneliness is lacking a circle of friends and acquaintances that can provide a sense of belonging, of companionship and of being a member of a community. [8]

A study found that increased age, absence of partner, dependency; institutionalization and health impairment were associated with increased risk of loneliness. Factors like cognitive function and limitations in activities of daily living were not related to loneliness. [9]

Loneliness is described as a chronic phenomenon which has been recognized as a strong correlate of depressive symptoms by many studies. [7] Though this varies across the life span, the association between loneliness and depressive symptoms appears to be stable across age and ethnicity. The magnitude of the association between loneliness and depressive symptoms has raised questions about their conceptual or functional separation. In fact in some measures of depressive symptoms, items about feeling lonely are included. [7]

In contrast, a study of the relationship between loneliness and depressive symptoms established a clear separation of the loneliness items and depression items into two distinct factors. Many other studies [7] have similarly found loneliness and depressive symptoms to form two separable entities using structural equation modeling. Also Weiss [10] has differentiated the two saying, "In loneliness there is a drive to rid oneself of one's distress by integrating a new relationship; in depression there is instead a surrender to it". [10]

Loneliness has been identified as a risk factor for depressive symptoms in cross-sectional and longitudinal studies of older adults, [7] but loneliness is associated with a constellation of demographic and psychosocial risk factors (e.g., hostility, low social support, perceived stress) for depressive symptoms. To what extent is the association between loneliness and depressive symptomatology attributable to its association with these other variables is not clear. A study for instance, reported a significant association between loneliness and depression even after controlling for demographic variables. [7] Heikkinen and Kauppinen [11] also reported evidence that loneliness predicted changes in depressive symptoms longitudinally. [11]

Whatever relationship they share, the mutually synergistic relationship of loneliness and depressive symptoms are responsible for increasing negativity in lonely and depressed individuals, and suggest that interventions at either or both fronts could reduce emotional suffering and improve well-being. [12]

Coping as defined by Folkman and Lazarus [9] is, "the person's constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as exceeding the person's resources". The way the difficulties are faced directly influences levels of health and psychological well-being. [9] Considerable variation is seen among the coping strategies which are used by the lonely and the choices of coping strategies are affected by the individual's age, life experience, cultural background, and the availability of methods of alleviating loneliness. [10] Previous studies have shown that common coping strategies used by elderly include active solitude, social contact, sad passivity, increased activity distancing and denial. [13],[14] Another study showed that emotion focussed coping such as acceptance and passivity are commonly used coping strategies in them. [15]

Past research is limited and hazy regarding the possible causal relationships between loneliness and depressive symptoms or their distinctness, though both probably share some common origin and determinants. [16] Also research in past is limited regarding relationship of loneliness and coping mechanisms in elderly. Thus, the current study was designed with aims of studying loneliness, depression and coping mechanisms in depressed and non-depressed elderly and also to study relationship between these factors.

Materials and methods

This was a cross sectional study carried out in the psycho-geriatric clinic of psychiatry outpatient clinic of a tertiary care teaching municipal Institute in Mumbai after obtaining requisite approval by the Institutional Ethics Committee. Depressed group included 46 patients diagnosed as having depression as per DSM IVTR criteria with age of 60 years or more and not having any other psychiatric, uncontrolled medical or surgical illness while non-depressed group included 48 subjects of age 60 or more and not having any medical, surgical or psychiatric illness. A written informed consent was taken from the subjects before commencing the study. The scales used were the Loneliness Scale, Geriatric Depression Scale [GDS: SF] and Brief Cope Scale. A semi structured proforma was used to collect the socio-demographic details of the subjects.

Loneliness Scale developed by De Jong Gierveld and Kamphuis [17] is an 11 items scale. The responses include ("more or less", "yes", or "no"). It has some positive and negative items. The loneliness scale total score ranging from 0 (not lonely) to 11 (extremely lonely) and has adequate psychometric properties (α = .84). The scale has proved to be a reliable and valid instrument. The scale has two subscales (one for emotional loneliness and one for social loneliness, with α = .88 and α = .88, respectively). The cut-off scores of 3 is used to distinguish between lonely and not lonely people. [17]

Geriatric depression scale (GDS) short form, first created by Yesavage et al[18],[19] has been tested and used extensively with the older population. Of the 15 items, 10 items indicated the presence of depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13) indicated depression when answered negatively. Scores of 0-4 are considered normal, 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression. The GDS has 92% sensitivity and 89% specificity. The validity and reliability of the tool have been supported through both clinical practice and research. [18],[19]

The Brief Cope Scale by Carver [20] is a self-report questionnaire used to assess a number of different coping behaviours and thoughts a person may have in response to a specific situation. It is made up of 14 subscales: Self-distraction, active coping, denial, and substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. These 28 coping behaviors and thoughts (2 items for each subscale) are rated on frequency of use by the participant with a scale of 1 (-I haven't been doing this at all) to 4 (-I've been doing this a lot). Internal reliabilities for the 14 subscales range from α = 0.57-0.90. [20]

Statistical Package for Social Sciences 20 th version (SPSS version 20) was used to analyze the data. Descriptive methods were used to study the demographical variables and frequency of other variables. Then inferential statistics was used to further analyze the data. Independent sample t tests were done to compute the statistical differences between the two groups. Pearson's bivariate correlation was used to study the relationship between coping mechanisms and depression and loneliness. Simple regression using the enter method was computed to determine the power of loneliness in predicting depression in the samples. Multiple regression analysis, with forward enter method was used to compute the power of emotional and social subscales of loneliness in predicting depression in the samples.

Results show that the mean GDS score of depressed patients (9.84), was significantly higher (t = 14.33, P < 0.001 *** ) than the mean GDS scores of patients who are non-depressed (3.20).

The mean loneliness score of depressed patients (7.98) was higher than the patients who are non-depressed (4.10), and this difference was also statistically significant (t = 7.23, P < 0.001 *** ). Significant difference was also seen on both emotional as well as social subscales between in the two groups (t = 8.99, P < 0.001 *** ; t = 4.07, P < 0.001 *** respectively).

Assessment of coping mechanisms in the two groups showed that self-distraction was the most common coping mechanism in depressed group and the least common coping mechanism was substance abuse, while in the non-depressed group active coping which is a healthy coping mechanism was most common while self-blame was least commonly used [Table 2].

Table 2: Shows the mean scores of coping mechanisms used in depressed and not depressed group

Simple regression was used to study relationship between the scores of depression and loneliness [Table 3], which showed that loneliness was a significant predictor of depression in both depressed as well as non-depressed group and it explained 51% of the variance in depressed group and 39% variance in non-depressed group.

Table 3: Relationship between loneliness and depression in depressed and non-depressed group

Multiple regression using forward enter method was used to study the power of emotional and social loneliness in predicting depression in these groups [Table 3]. Both emotional and social loneliness emerged as significant predictors of depression in both the groups. In the depressed group social loneliness (R square = 47%) explained higher variance in depression than the emotional loneliness (R square = 37%) while in non-depressed group the reverse was seen.

Also when entered together in the regression model, only emotional loneliness predicted depression in non-depressed (t = 5.837, P < 0.001 *** ), while only social loneliness predicted depression in the depressed group (t = 3.489, P = 0.001 *** ).

For further analysis of relationship between depression and loneliness, the data was taken as divided into these four groups on the basis of presence or absence clinical depression, cut off scores for GDS and loneliness scale as shown below. After which groups were divided as group N (18%) in which subjects did not had significant score on GDS, loneliness scale or clinical diagnostic criterion. Group L (only loneliness) (18%) had significant scores only on loneliness scale and not the rest of them. Group GL (loneliness and subsyndromal depression) had significant scores on GDS as well as loneliness but did not fulfil clinical criterion, and the fourth group had all of them positive group CGL (had high scores on loneliness and had syndromal depression). The GDS and loneliness score had an increasing trend while moving from Group N→L→GL→CGL (GDS-2.35, 2.23, 5.42 and 9.78 in N, L, GL and CGL groups respectively, mean loneliness scores-1.41, 4.41, 7 and 7.97 in the same order) as shown in [Figure 1].

Figure 1: Shows the mean scores of GDS and loneliness among the 4 groups

[Figure 2] shows analysis of responses to loneliness scale questions which revealed that in the N and L groups which had not fulfilled clinical criterion for depression the responses in loneliness scales were mostly on the questions, 'I find my circle of friends and acquaintances very limited', 'I miss having a really close friend' and 'I can call on my friends whenever I need them'. As we move towards the GL and CGL group, along with above questions responses to other questions like, 'I miss having a really close friend', 'I miss the pleasure of the company of others' and 'I experience a general sense of emptiness', also appeared predominantly along with the previous questions.

Figure 2: Shows analyses of responses to questions of loneliness scale of subjects from various groups

On studying the relationship between severity of depression on GDS scores and various coping mechanisms by using Pearson's bivariate correlations [Table 4] it was found that in the depressed group increased use of denial, behavioural disengagement, and self-blame as coping mechanism was associated with increased scores on GDS meaning more depression. Also increased use of ways of coping like self-distraction, active coping, emotional support, venting, positive reframing, planning, humor and religion was associated with less scores on GDS meaning lesser depression. In the non-depressed group increased use of active coping, emotional support, instrumental support and venting, humor was associated with lesser scores on GDS (negative correlation) while none of the coping mechanism showed positive association with GDS scores.

Table 4: Showing relationship between subscales of coping with GDS score and with Loneliness scores in the two groups (The values indicate coefficients of correlation)

On correlating coping mechanisms with loneliness using Pearson's bivariate correlations in both groups [Table 4] it was found that in the depressed group increased use of denial, behavioural disengagement, and self-blame as coping mechanism was associated with increased loneliness. Also increased use of ways of coping like self-distraction, active coping, emotional support, instrumental support, venting, positive reframing, planning, and humor was associated with lesser scores on loneliness scores meaning lesser loneliness. In non-depressed group self-distraction, active coping, emotional support and instrumental support had significant correlation with GDS scores and were associated with decreased loneliness scores; none of the mechanisms was associated with more loneliness.

[Figure 3] shows group-wise distribution of various coping mechanisms (4 groups) which shows that denial, self-blame, behavioural dis-engagement were significantly more in depressed group and showed a decreasing trend while moving towards the normal group, while other coping styles like religion, planning, positive reframing, active coping, venting, self-distraction, emotional and instrumental support were less commonly used by the depressed group and had increased trend while moving towards the non-depressed group.

Figure 3: Showing group-wise use of various coping mechanisms in the N, L and CGL (depressed) group

Results of the study showed that GDS scores were significantly higher in the depressed group than in the non-depressed group as expected, which is consistent with the fact that GDS has proven capacity for discriminating between depressed and non-depressed elderly people [21] even if they have some other associated co-morbities like arthritis or cognitive impairment in senile dementia. [19] Our study also shows that loneliness (both emotional and social subscales) was significantly higher in depressed group than in the non-depressed group which is in accordance with the fact that loneliness is a significant risk factor for depressive symptoms and has strong association with depressive symptoms in both men and women. [7] Also as people grow old, the likelihood of experiencing age-related losses increases, resulting in a higher incidence of loneliness. When this occurs in combination with physical disablement, depression is common. Further both external (social support) and internal (personality and psychological) factors affecting loneliness differ in these two groups [22] significantly which can explain the difference on the emotional and social subscales.

Active coping which is an adaptive and healthy coping style [23] was the most common coping method used in non-depressed group while self-distraction a maladaptive coping mechanism was more commonly used by depressed group. Previous studies have shown that common coping strategies used by elderly include active solitude, social contact, sad passivity, increased activity and distancing and denial. [13],[14] Alsoa study by Holahan et al. [24] showed that avoidant coping is positively associated with depressive symptoms in a ten year longitudinal study. [24]

Our study showed that loneliness is a significant predictor of depression in depressed as well as non-depressed group similar to a previous study which showed that loneliness explained 8% of the unique variance in the depression scores. This suggests that loneliness is an independent risk factor for depression and increase in loneliness predicts a significant increase in depressive symptoms. [25] On further studying the predictive powers of subscales of loneliness it was found that both the emotional and social subscales predicted depressive symptoms in depressed as well as non-depressed group.

A study by Chlipala [25] similarly showed that poor perceived social support leads to poor mental health and depressive symptoms [25] and a study in India by Misra [26] revealed that old age related losses, impede the maintenance or acquisition of desired relationships (emotional loneliness) of which depression is a common companion. [26]

In the depressed group social loneliness was found to be stronger predictor of depression either alone or when considered together with emotional loneliness while in the non-depressed group emotional loneliness predicted depressive symptoms more significantly similarly. There is dearth of research studying the relationship of emotional and social loneliness separately or taken together, with depression. In spite of that, in the depressed group the more prediction of depression by social loneliness may be explained by the poor quality and quantity of social relationships and less number of friends (poor socialization) in them which are among the strongest predictors of depressive symptoms and thus the vicious cycle is propelled further. [27] Similarly in non-depressed more prediction by emotional loneliness may be due to lack of meaningful relationships resulting from the losses associated with old age and physical disabilities, which leads to inner emptiness, [28] which is the core of emotional loneliness.

GDS and loneliness showed an increasing trend from L to CGL, indicating a presence of continuum with normality at one end and a combination of loneliness and depression at the other, through a distinct stage where only loneliness is present indicating it as a distinct concept, different from depression. Also on item wise analysis of responses in the normal (N) and lonely (L) group the responses were mostly related to deficient social network, especially friends which is common in old age as previously described, but while moving towards the CGL group through L and GL Along with these answers, other responses consistent with negative percept of depression also became predominant which further supports continuum hypothesis. A lot of studies in past have shown that depression and loneliness appear to be two interrelated, yet distinct constructs. [7],[29],[30] Another study found a moderate positive correlation between depression and loneliness however, there were different significant predictors associated in the regression models, highlighting the differences in the two constructs. [29] Also despite the fact that loneliness is not treated as a specific clinical variable, several studies have presented evidence on the uniqueness of loneliness as a phenomenon in its own right, [31],[32] however as most of the above studies have not been done in elderly or have been done in retirement homes, also our cultural and social differences may preclude us from generalising it to Indian population. Our results can represent the Indian perspective to above past research.

Our study also revealed that, in the groups, GDS scores increased significantly after loneliness score reached significant levels and vice versa, so with this and previous predictive relationship between loneliness and depression we may infer that loneliness predicts as well as precedes depression and have synergistic relationship with it. This is rightly supported by Cacioppo and Hawkley [12] saying, 'mutually synergistic effects of loneliness and depressive symptoms are consistent with a downward spiral of negativity in lonely and depressed individuals'. [12]

Coping mechanisms are associated with the patient's understanding of his disease/symptoms and the ways in which he manages his illness. A study [23] has divided coping mechanisms from brief cope scale into Adaptive (Active coping, instrumental support, planning, acceptance, emotional support, humor, positive reframing and religion) and Mal-adaptive (Behavioral disengagement, denial, self-distraction, self-blame, substance abuse and venting). Our study found that use of adaptive coping strategies was associated less scores on GDS and loneliness scores while use of mal-adaptive coping strategies had inverse relationship with GDS and loneliness scores. Also in the 4 groups that were analysed use of adaptive coping strategies showed increasing trend while moving towards N group while mal-adaptive coping strategy use showed increased trend in the opposite direction suggesting significant contribution of coping strategies in predicting depression and loneliness.

This is supported by previous studies, which showed that active coping produced less or no depressive symptoms and less distress, whilst passive coping strategies produced more symptoms in depressed as well as non-depressed elderly. [33],[34] Also previous studies have shown that instead of responding with optimism and active engagement, lonely people tend to respond with pessimism and avoidance which are passive coping strategies. Similarly, the greater the loneliness, the less the individual sought out emotional support, as well as instrumental (practical) support. [35]

This study was limited by cross sectional design. However we can conclude that loneliness is an important factor predicting and probably preceding depressive symptoms in elderly so mental health professionals need to look out for loneliness in assessment for depression, in order to intervene at an early stage and also to try that this synergistic dyad of negativity can be circumvented. Use of coping strategies also seem to affect depression as well as loneliness in elderly so elderly patient having either loneliness or depression be advised regarding use of adaptive coping strategies. And last but not the least as social loneliness predicts depressive symptoms more significantly, working on social factors through interventions like mutual help groups, friendship programmes and other social interventions also becomes necessary.

Jones DA, Victor CR, Vetter NJ. The problem of loneliness in the elderly in the community: Characteristics of those who are lonely and the factors related to loneliness. R Coll Gen Pract 1985;35:136-9.